E/M Coding Education: Does ‘No SOB’ Fall Under HPI or ROS?

October 12, 2009

Question: For a chart with a chief complaint of resolving pneumonia, a note indicates, “No coughing, SOB.” Should I give the pediatrician credit for this ‘no coughing & no shortness of breath’ statement under history of present illness (HPI) or as a review of systems (ROS)?

Answer: This is a gray area of E/M coding that you can count under either history type. You could give credit for “no coughing” and “no shortness of breath” (SOB) as associated signs and symptoms under HPI. Some auditors might instead count the notation as a review of the respiratory system under ROS.

Do you use evaluation & management codes? Expect big changes for 2010. (Hint: No more consultation coding.) Chart your course with our 2010 E/M Coding Update Audioconference.

Related articles:

E/M Coding Focus: Geriatric Patients & DementiaDetermine HPI or ROS during assessment for geriatric patients. Your…
Mid-Level E/M Coding BreakdownOur chart shows you how to choose among 99212, 99213 &…
Test Your E/M Coding & Billing Savvy Are you an E/M Emeritus? Take this quiz to…

Share:

More Posts

Last-Minute Tips For Creating An ICD-10 Command Center

When the clock ticks in a new month and the entire healthcare industry is thereby mandated to begin using the new ICD-10 code set, there

ICD-10 Data: Does It Matter?

It is often argued that ICD-10 coding does nothing for the patient. Recently that point was made at the U.S. House Energy & Commerce Subcommittee on Health hearing “Examining ICD-10 Implementation” last week.

Researchers Create Online Tool To Ease Transition to ICD-10 Codes

Researchers have developed an online mapping tool designed to help stakeholders transition from ICD-9 to ICD-10 code sets, EHR Intelligence reports.

Know your Priorities When it Comes to ICD-10: Five Areas that Deserve your Attention Now

The next nine months are critical in terms of preparing for a smooth transition to ICD-10. If ICD-10 isn’t a priority in your organization yet, it should quickly rise to the top of the list as soon as possible.

There’s not enough incentive to keep health care data safe

The grim message following a breach that has endangered sensitive data belonging to 80 million current and former Anthem health insurance customers is that we can only expect more health care data breaches in the future.